Nixon Tonkin inquest: 'I was in labour for two days and they hand me my dead son'

Simone and Martin Tonkin, with Nixon's body just after the birth. Photo: Supplied

On the bedroom wall of a Gold Coast home there's a special spot reserved for the most painful of memories.

The Tonkins leave the Brisbane Magistrate Court after the coronial inquiry into their son's death. Photo: Tammy Law

At a glance, he could be peacefully sleeping, but little Nixon Tonkin never breathed on his own.

Instead, his framed image, posed just hours after his traumatic birth and death, hangs opposite Simone and Martin Tonkin's bed, along with casts of Nixon's hands and feet.

Knox Tonkin will never know his big brother. The two-year-old can say Nixon's name. He knows the photos but he's still too young to understand why he's not there.

It's June 3, 2014, when Simone is taken to the Royal Brisbane and Women's Hospital, at 38 weeks' pregnant and suffering hypertension

The first-time parents are excited, nervous, looking forward to having their baby home.

"You're holding onto that baby and you don't want to let it go." Photo: Supplied

The former financial planner won't give birth for another two days after falling into what she describes as a "black hole" of others making decisions for her.

Her qualms stem back to when she was 22 weeks' pregnant and first brought up the topic of an elective caesarean, going on to raise it multiple times.

Martin was a 10-pound baby and now stands "six-foot something". She's 5'1" and weighed only eight. It's genetics, she feels, and a mother's intuition.

"I thought, 'I'm going to have a pretty big baby'," she says.

It's the morning of June 6 and almost two hours after Simone starts pushing, doctors opt for an emergency caesarean after realising Nixon's head is stuck in the birthing canal.

At 1.40pm, Nixon is declared dead, his skull likely crushed by the two fingers of a midwife, a woman who should never have been put in that situation and who Simone doesn't blame.

"I was in labour for two days and then they hand me my dead son," the 36-year-old says, emotion tugging at the edges of her words.

"You can't even fathom what you're supposed to do in that situation, how you're supposed to act. It was horrible.

"I guess you want to hold onto anything tangible you can so you're holding onto that baby and you don't want to let it go."

Three years after the death, Deputy State Coroner John Lock will find no individual staff member responsible, instead criticising some of the hospital's practices and communication.

Many of those will have since been updated in response.

By the time it got to the birth, hospital staff assumed Simone had been properly consulted and opted for a vaginal birth. She had not.

Little Knox Tonkin will never know his big brother. Photo: Supplied

"It was horrible," she says. "To be a human being and feel like you have no decisions in what happens to you or that your voice is taken away, I started to second-guess myself.

"Do I know what I'm talking about? Should I just do what everyone is telling me is happening?"

Mr Lock finds an earlier shift to a caesarian could have saved Nixon's life. An even earlier elective caesarean, while carrying its own risks, would have seen "little to no likelihood" of the baby's head becoming lodged in a similar fashion.

"I knew that every time I saw a consultant, I told them that I wanted to have a caesarean," Simone says.

"I feel a lot of guilt now because I feel like maybe I should have been more aggressive, maybe I didn't advocate for myself well enough but then I sort of have to take a step back and (think) 'how aggressive do you need to be?' "

It's March 20, 2017, and Simone's midwife, whose name has been suppressed, is on the stand in the Coroners Court in Brisbane, being grilled about her role in the death.

An autopsy found the baby's skull most likely fractured when the woman used two fingers, instead of the recommended cupped hand, in an "understandable" attempt to free the baby's head.

Early reports on the inquest focus heavily on the midwife's role but Mr Lock finds no fault, saying she should never have been put in that position, and Simone agrees.

When the midwife is done with her evidence, the bereaved mother rushes outside to comfort her, give her a hug.

"That broke my heart because she was certainly not at fault and even before the findings came out, I never blamed her," Simone says.

"She was put in this situation where she did the best that she could with the skills and the knowledge that she had.

"To see her give evidence was heartbreaking."

The inquest hears evidence the RBWH had a culture of preferring vaginal births to c-sections.

Mr Lock ultimately rejects the notion but for Simone her autonomy as a pregnant mother, or lack of it, is at the heart of everything.

She feels like she wasn't listened to, something borne out to at least some extent by the evidence of independent specialist obstetrician Dr Robert Lyneham.

He tells the court patient autonomy is "extremely important" but almost everyone asks for a c-section in the second stage of labour, and his comments wouldn't apply to a woman at this stage.

Sarah Atkinson, medical negligence principal at Maurice Blackburn, the firm that represented Simone at the inquest, says patient autonomy is a much wider issue.

"So I think it used to be quite a paternalistic relationship where the doctor knew best and the doctor made the decisions for the patient and the patient just went along with them and probably quite often was not even consulted," she says.

"And I think there's been a gradual shift to greater patient autonomy but I think sometimes it's not got sort of far enough."

It's July 2015 and Simone is "terrified", 34 weeks pregnant with Knox but she's lost what she describes as the "innocence" of not having a first child.

The "traumatic" scenes of Nixon's birth come back to her - pushing and pulling, voices, the feel of her body.

It's PTSD, she says, the smell of a hospital immediately bringing her back.

The Tonkins go private this time, with an obstetrician, midwife and even psychologist on board to help them through.

"Once I saw Knox, it was obviously such a huge relief," she says.

He's almost two years old now but his big brother's death still leaves a shadow and Simone wants to change the medical community's approach to consulting with patients.

"You can't dismiss how someone feels just because they're in labour," she says. "We're not neurotic, pregnant mums. We know our bodies. We have intuition."

Royal Brisbane and Women's Hospital Clinical Director of Obstetrics and Gynaecology Associate Professor Karin Lust said the hospital had overhauled its maternity services since 2014.

"In rare and unusual events such as these, it's important that we look at what could have been done differently," she said, in a statement.